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Disturbed Thought Process related CNS infection by HIV, brain malignancies, and/or

disseminated systemic opportunistic infection evidenced by Altered attention span; distractibility,


Memory deficit, Disorientation, delusional thinking and sleep disturbances

Goal

To maintain usual reality orientation and optimal cognitive functioning.

Nursing Interventions Rationale


Assessment of mental and neurological status Establishes functional level at time of admission
using appropriate tools. and provides baseline for future comparison.
May contribute to reduced alertness, confusion,
Assessment for anxiety, grief, and anger. withdrawal, and hypo activity, requiring further
evaluation and intervention.
Actions and interactions of various medications,
prolonged drug half-life and/or altered excretion
rates result in cumulative effects, potentiating
Monitoring medication regimen and usage. risk of toxic reactions. Some drugs may have
adverse side effects: haloperidol can seriously
impair motor function in patients with AIDS
dementia complex.
Changes may occur for numerous reasons,
Investigation of changes in personality,
including development or exacerbation of
response to stimuli, orientation and level of
opportunistic diseases or CNS infection. Early
consciousness; or development of headache,
detection and treatment of CNS infection may
vomiting, fever, seizure activity.
limit permanent impairment of cognitive ability.
Maintaining a pleasant environment with Providing normal environmental stimuli can
appropriate auditory, visual, and cognitive help in maintaining some sense of reality
stimuli. orientation.
Providing cues for re-orientation. For example Frequent reorientation to place and time may be
use of patients name, identifying self, necessary, especially during fever and/or acute
maintaining consistent personnel and structured CNS involvement. Sense of continuity may
schedules as appropriate. reduce associated anxiety.
Familiar contacts are often helpful in
Encouraging family and to socialize and provide
maintaining reality orientation, especially if
re-orientation with current news, family events.
patient is hallucinating.
Nursing Interventions Rationale
Encouraging patient to do as much as possible: Can help maintain mental abilities for longer
dress and groom daily, see friends, and so forth. period.
Promotes sleep, reducing cognitive symptoms
Decreasing noise, especially at night.
and effects of sleep deprivation.
Maintaining safe environment, and soft Provides sense of security and stability in an
restraints if indicated. otherwise confusing situation.
Administer medications as indicated:
Shown to improve neurological and mental
Antiretroviral drugs alone or in combination
functioning for undetermined period of time.
Cautious use may help with problems of
Antipsychotics: haloperidol, and/or antianxiety
sleeplessness, emotional lability, hallucinations,
agents: Diazepam
suspiciousness, and agitation.
May help patient gain control in presence of
Refering to counseling as indicated. thought disturbances or psychotic
symptomatology.

Anxiety related to threat of death, change in health/socioeconomic status, role functioning, fear of
transmission of the disease to family/loved ones evidenced by increased tension, apprehension,
feelings of helplessness/hopelessness, expressed concern regarding changes in life, fear of
unspecific consequences, somatic complaints, insomnia and restlessness.

Goal

Patient will be able to;

Verbalize awareness of feelings and healthy ways to deal with them.

Display appropriate range of feelings and lessened fear/anxiety.

Demonstrate problem-solving skills.

Use resources effectively.


Nursing Interventions Rationale
Provides reassurance and opportunity for
Assuring patient of confidentiality within limits
patient to problem-solve solutions to anticipated
of situation.
situations.
Provides assurance that patient is not alone or
Maintaining frequent contact with patient. rejected; conveys respect for and acceptance of
the person, fostering trust.
Providing accurate, consistent information
Can reduce anxiety and enable patient to make
regarding prognosis and avoiding arguing about
decisions and choices based on realities.
patients perceptions of the situation.
Patient may use defense mechanism of denial
and continue to hope that diagnosis is
inaccurate. Feelings of guilt and spiritual
Being alert to signs of withdrawal, anger, or
distress may cause patient to become withdrawn
inappropriate remarks as these can be signs of
and believe that suicide is a viable alternative.
denial or depression and determining presence
Although patient may be too sick to have
of suicidal ideation.
enough energy to implement thoughts, ideation
must be taken seriously and appropriate
intervention initiated.
Providing open environment in which patient Helps patient feel accepted in present condition
feels safe to discuss feelings or to refrain from without feeling judged, and promotes sense of
talking. dignity and control.
Permitting expressions of anger, fear, despair
without confrontation and giving information Acceptance of feelings allows patient to begin
that feelings are normal and are to be to deal with situation.
appropriately expressed.
Recognizing and supporting the stage patient Choice of interventions as dictated by stage of
and/or family is at in the grieving process. grief, coping behaviors
Explaining procedures, providing opportunity
Accurate information allows patient to deal
for questions and honest answers. Arrange for
more effectively with the reality of the situation,
someone to stay with patient during anxiety-
thereby reducing anxiety and fear of the known.
producing procedures and consultations
Reduces feelings of isolation. If family support
Identifying and encouraging patient interaction
systems are not available, outside sources may
with support systems.
be needed immediately
Ensures a support system for patient, and allows
significant others the chance to participate in
Including patient and significant others as
patients life. If patient, family, and significant
indicated when major decisions are to be made.
others are in conflict, separate care
consultations and visiting times may be needed.
May require further assistance in dealing with
Referring to psychiatric counseling. diagnosis or prognosis, especially when suicidal
thoughts are present.
Social Isolation related to, altered state of wellness, changes in physical appearance, alterations in
mental status, perceptions of unacceptable social or sexual behavior/values, inadequate personal
resources/support systems, physical isolation evidenced by expressed feeling of aloneness
imposed by others, feelings of rejection absence of supportive significant others: partners, family,
acquaintances/friends.

Goals

Patient should be able to;

Identify supportive individual(s).

Use resources for assistance.

Participate in activities/programs at level of ability/desire.

Nursing Interventions Rationale


Isolation may be partly self-imposed because
Ascertain patients perception of situation.
patient fears rejection/reaction of others.
Spending time talking with patient during and Patient may experience physical isolation as a
between care activities, being supportive, result of current medical status and some degree
allowing for verbalization and treat with dignity of social isolation secondary to diagnosis of
and regard for patients feelings. AIDS.
Reduces patients sense of physical isolation
Limiting or avoiding use of mask, gown, and and provides positive social contact, which may
gloves when possible and when talking to patient. enhance self-esteem and decrease negative
behaviors.
When patient has assistance from SO, feelings
of loneliness and rejection are diminished.
Identifying support systems available to patient,
Patient may not receive usual or needed support
including presence of and/or relationship with
for coping with life-threatening illness and
immediate and extended family.
associated grief because of fear and lack of
understanding (AIDS hysteria).
Gloves, gowns, mask are not routinely required
with a diagnosis of AIDS except when contact
with secretions or excretions is expected.
Misuse of these barriers enhances feelings of
Explain isolation precautions and procedures to
emotional and physical isolation. When
patient and significant others.
precautions are necessary, explanations help
patient understand reasons for procedures and
provide feeling of inclusion in what is
happening.
Nursing Interventions Rationale
Helps reestablish a feeling of participation in a
Encourage active role of contact with significant
social relationship. May lessen likelihood of
others.
suicide attempts.
Indicators of despair and suicidal ideation are
Being alert to verbal or nonverbal cues:
often present; when these cues are
withdrawal, statements of despair, sense of
acknowledged by the caregiver, patient is
aloneness and assessing patient for thoughts of
usually willing to talk about thoughts of suicide
suicide .
and sense of isolation and hopelessness.